Loading...
HomeMy WebLinkAboutMiscellaneous - 55 EQUESTRIAN DRIVE 4/30/2018 55 EQUESTRIAN DRIVE -ive _ 210/105.D-0148-0000.0 I t <� I i I i i ° ~ ` '. . ` ~ & MAP # LOT # ��' PARCEL # STREET____ __ CONSTRUCTION- APPROVAL. HAS PLAN REVIEW FEE BEEN PAID? NO PLAN APPROVAL: DATE APP. BY_~.,�� _ DESIGNER: 64, PLAN DA | E _� -����^��__ CONDITIONS -__.....__- - - --------'- - WATER SUPPLY: WELL (:T�O WELL PERMIT. DRILLER__ .' WELL TESTS: CHEMICAL DA| E APNRUVED _ _ _ 8ACIERIA l Dn{ L U!l4<UVED ' BACTERIA Il DA|E Al'PHUVEU COMMENTS: APPROVAL TU I6�UE YES NO FORM U APPROVAL: ' ^ DATE ISSUED CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID H ESUU WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL wU OTHER YES HU ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DAlL: BY : SEPT I_G._-S_Y_SZEM-JNS.T9.4.L.A_TI_QN. IS THE INSTALLER LICENSED? YES NO ' TYPE. OF CONSTRUCTION: NEW REPAIR NEW CONSTRUCTION: CERTIC-IED PLOT PLAN REVIEW Yl--s 110 CONDITIONS OF APPROVAL YES No (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. (n INSTALLER: �'Q�A'p 1� \�,C'_ BEGIN .INSPECTION YES NO: EXCAVATION . INSPECTION: NEEDED: Q A ,� PASSED ��Z���7� HY __��---� _------ CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES, APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE:________E3Y_ 0207056925 09/2212005 Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System Owner System Location 'SlaL.ter-y Shai-in Primary 13rme 55 EqueNtrian Drive 55 Equeutrian Drive T!orth Andover, MA, 01845 North Andover, VA, 01845 (978)--683-1166 x (978)-683-1166 x Slattery Shawn Type: Emergency Routine Cesspool: No IAes Septic Tank: No Yesl - Date of Pumping: b \' Quantity Pumped: 6�6Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: t r td 0 9 12015 Contents Disposed at: 1�/5 I� Date: Pumper Signature: Condition of System/Other Comments vV � ® Printed on recycled paper Dep Approved Form-12/07/95 �L\ Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used,but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351, A. Facility Information Important; When Ming out 1. System Location' forms on the `EE,,q computer,use _._. — •.. i t i_. �_. only the tab key AdWres to move youp /Cursor d0 qol .r .� a-t/.�.1 _. .,..., .._ ......... - . use the raturrm Cityrrown tate Zlp Code key. 2. System Owner, f Name Address Of different from location) •dity/Town State IT COe .. Jd.: t_. ..,.... .,. Telephone Number B. Pumping Record — 1. Date of Pumping O�tB _ 2. Quantity Pumped: Gallons 3. Type of system: [] Cesspool(s) Septic Tanis ❑ right Tank ❑ Grease Trap ❑ Other(describe): -- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of System: 19 � 6. Syste Pu ped By: Name Vehide Lic ftaa Number Comps y 7. Location where contgnts were disposed: Signah reof Haul r 94lr8lpre of Receiving Facility Date t5fvrm4,dac•03106 System Pumping Recd•Page 1 of 1 DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, March 22, 2010 12:10 PM To: DelleChiaie, Pamela Subject: junk complaint to input Last Friday afternoon Anonymous complaint phoned in Regarding the old Greenery property Complainant states: Current owner is Sean Slattery who lives t55Equestrian, North Andover. This multi-unit home was split off from "the greenery" and is rented as apartments. Behind the building;out of view from the road there is a lot of debris piling up. Old appliances and junk.This property was cleaned up initially and is now a problem again. S. Sawyer told the complainant that we don't have jurisdiction over eyesores and that we would need to be able to view any potential violations to document them.So there will be no formal investigation. I did indicate that I may attempt to contact the owner and relay the concerns. But no action is to be taken against this owner. 1 1 0 TO g NORTH ANDOVE �o • 7SYSTE PiJMPXNG RECORD � r 11 DATE ,�- --0 ; SYSTEM OWNER&ADDRESS SYSTEM LOCATION ' Al DATE OF PUMPING -'p y _ QUANTITY PUMPED CESSPOOL NO ,/ YES SEPTIC TANK NO YES J NATURE OF SERVICE: RO'UTME---,4/— EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS — LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY j✓l' �eG �" COMMENTS: CONTENTS TRANSFERRED TO � i I i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) �S�Lte7GC� DATE OF PUMPING: QUANTITY PUMPEDGALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES (/ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION _� FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: Adt mss R_��-,� lJ Title of File Page g of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department � G. TOWN OFAANDOVER SEPTIC SYSTEM SF'RVICING :REPORT Date: Homeowner: -t_U Street Pumper Phone _-�1 Address: Phone Nature of S '-rvice: Routine Emergency Observation:; : Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description: of Work: ------ v - FEB 10-- Comments : SOIL PROFILE * PERCOLA'T'ION TEST DATA 'Town/City No.&Street 9 . �L � G��� � Lot Na. Loc. /Subdiv : Plan Oti-.ner Invest_i_gator Observer SOIL PROF'ILE'S-DATE 1 . 2 . ;f f 3 3 . 4 . El,ev. — Elev. -- Elev. —Elev . 0 0 0 XPi X11 Sufi 2 2 2 2 3 3 � 3 <) 3 14, _ 4 ° �� _. 4 4 5 5 l 5 Q V b L b _ � 6 t� �G 7 . 't' 7 7 8 8 - 4A `9 9 9 9 10, 10 10 10 Benchr.lark Location „Elevation Datum ercolatio_n Tests-Date Pit Number 2 4 S Start Saturation _A �Q V, Soak-" ns. �' Start '.Fest-Time .Drop of 3"-Time AM M _ Drop c�.f 6"-Timr Miris . lst 3"Dr_op Mins . 2nd 3"Dro (�- .,Notes & Sketches on Back Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts \ System Pumping Record `c— System Owner System Location Type: Emergency Routine Cesspool: No Yes PET Septic tank: NoYes �J Date of Pumping: Quantity Pumped: � Gallons System Pumped By: Wind River Envinaaranto% LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 OFFICE WILMINGTON PLANT (508)664-3101 CUSTOMERS COPY (508)658-3602 HEFFRON MATERIALS A DIVISION OF HEFFRON ASPHALT CORP. PLANT:SALEM ST.RT 62 WILMINGTON,MASS.01887 P.O./JOB NO. DATE i SOLD TO ' DELKYERED TO THIS COMPANK RESPONSIBLE OTHER FOR ANY DADELVERIES BEYONDRB LINE. SCREENED WASHED AND MILTIE CRUSHED BANK SAND SAND ILL PACK GRAVEL GRAVEL ' PEA V2" 3 yz,. 1' ST• E 10% STONE T TO . REAT AS D SA TONS TRU N 1 GROS P E AT TAX NET / <� TOTAL 't f DRIVER . )-,r,, 'ORN WEIGHER /¢'r No H159971 BRADY BUSINESS-5 LO ELL MA 01852 210263-13J OFFICE WILMINGTON PLANT .-(508)664-3101 CUSTOMERS COPY (508)658-3602 HEFFRON MATERIALS A DIVISION OF HEFFRON ASPHALT CORP. r PLANT:SALEM ST.RT 62 WILMINGTON,MASS.01,88, I P.O./JOB NO. DATE \ ------- __ SOLD TO DELI RSD TO THIS COMPANY NOT RESPONSIBLE OTHER FOR ANY D AGE ON DELIVERIES BEYOND THE CURB LINE. SCREENimigN HE D SHANK SAND JAVErGRAVEL to usti PEA %2" 3ja" lYz° 11/2"S10 E 10% R STONE STONE STO TO DOU E EATED E ND TONS lacly O. pft GROSS J PRICE TARE � /' � � TAX NET \ TOTAL i DRIVER '7RN WEIGHER No H159992 BRADY BUSINESS FORMS LO ELL MA 01852 210263-9J ACE WILMINGTON PLANT j08)664-3101 CUSTOMERS COPY (508)658-3602 '- HEFFRON MATERIALS A DIVISION OF HEFFRON ASPHALT CORP. I , PLANT:SALEM ST.RT 62 WILMINGTON,M�S,SJ 7' P.O./JOB NO. r SOLD TO DEUV THIS COMPANY PO HER FOR ANY DA A ON LIV E BEYOND T UR I SCREENED W E AN MI HE B K SAND I P G E G PEAu It IV2 1 e'S o STONEW'N! E TO 1 AS AN V. TONS TRU K 0. GROSS PRICE TARE rA � TAX c 1 NET � © � TOTAL DRIVER 'VORN WEIGHER �B �' ( � -t No H159993 ` BRADV SI 5 ORMS L ELL MA 01852 210283-BJ 1 F` o� . � � �- 1 Y�� _ i ��� Ste, .� y . . - , � . �, OFFICE WILMINGTON PLAN' (508)664-3101 CUSTWER'S COPY (508)658-360 HEFFRO"ATERIALS A"DIVISION'OF HEFFRON ASPHALT CORP. PLANT:SALEM ST.RT 62 WILMINGTON, MASS.01887 P.O./JOB NO. rt^ DATE SOLD TO410 D RSD O THIS CO NYIS NOT RESPONSIBLE OTHER FOR DAON DELIVERIES ` EYDAM THE CURB LINE. SCREENED WASHED 'SAND MILTIE CRUSHED BANK SAND SAND FILL PACK GRAVEL GRAVEL ruL PEA Yi' /2' fD E 10', STONETON. , S N O O TED i D ti r ray _— c.� TONS 43 ` GROSS Elt t. TARE TAX NET [TOTAL DRIVER SWORN WEIGHER REC'DBY ,NU H160020 BRADY BUSINESS FORMS-ELL MAO 1852 210263.BJ ' Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH Of ti�ao ;a,MO o DISPOSAL WORKS CONSTRUCTION PERMIT SSACMUSE Applicant ,aL 4 b-L ST— NAME ADDRESS TELEPHONE Site Location LT St 4 Permission is hereby granted to Construct V) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. �(� PLAN REVIEW CHECKLIST ADDRESS �y. �,d A/1 ��ENGINEER GENERAL 3 COPIES �� STAMPy� LOCUS t/ SCALE CONTOURS L-- PROFILE ✓ SECTION BENCHMARK ELEVATIONS - SOIL & PERC INFO WETS. DISCLAIMER -- WELLS & WETLANDS L� WATERSHED DISTRICT DRIVEWAYWATER LINE DRAINS RESERVE AREA Z/ SCH40 ✓` SLOPE SEPTIC TANK MIN 1500G. . 17 INVERT DROP �~ GARB. GRINDERV(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE �` ELEV0A1 GW_6,L D-BOX # OUTLETS FIRST 2' LEVEL STATEMENT INLET - OUTLET/6 = �� (2" OR . 17 FT) LEACHING 100' TO WETLANDSy 100' TO WELLS 325' TO SURFACE H2O SUPP — 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW 2% SLOPE 4' PERM. SOIL BELOW FACILITY f/ MIN 12" COVER c/ FILL? t/—(-25' if above natural elevation; 101if below) T E�nC' ES �1 t0 ILk. MIN 660 FT2__,z SLOPE (min . 005 or 6"/1001 ) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. BOT X LDNG + SIDE X LDNG = TOT .7o J- G (L x W x #) (G/ft2) (DxLx2x#) DATE � c� C�� �---- Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEET�i' PERMIT # DATE RECEIVED APPLICANTe ASSESSOR'S MAP ADDRESS PARCEL # LOT # / Q� ENGINEER STREET-L�; OI}1�D.n ADDRESS -lrD Deer /l'la PLAN DATE //s/qj, REVISION DATE CONDITIONS OF APPROVAL: APPROVED �. DISAPPROVED i REVIEW CON`1'INUED SHEET OF ro �r5Y FA�D W� lee rn�0 �� . s �siztP� �cSC� S IDos� � n, (�. �7(0 ft= i v�� 1 Vk �/ter �',��� f �T- ��iZ€�c-�vz'�r7uc Town of North Andover, Massachusetts Form No. 1 Q NORTH BOARD OF HEALTH F q ' SLED ib tiO 3? y� `6 QL 19 APPLICATION FOR SITE TESTING/INSPECTION 7 ADRATED PPP'�h gSSACHUSE� Applicant NAME ADDRI' TELEPHONE Site Location 31 zcpl'6MAK-11 Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. �'4� S.S. Permit No. 31 D.W.C. No. t S7 C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 I NORT#j A BOARD OF HEALTH O �1"' '6�,YQ 3? y� '6 0� 19 o m APPLICATION FOR SITE TESTING/INSPECTION SSACHUs���h Applicant NAME 1 ADDRESS TELEPHONE Site Location -- Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. BOARD OF HEALTH No.Andover, Dass . SUBSURFACE DISPOSAL DESIGN CHECK LIST 2 l LOT J '�/ APPROVED DATE � DISAPPROVED DATE Provided: Q�l -z4� ' �// Reasons: � Title V FAIL 0g Reg 2.5 The submitted plan must show as a pinimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas Athin 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1.00' of sesage disposal system or disclaimer-Planning Board files (J) knova sources of water supply within 2001 of sewage disposal e system or disclaimer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other' elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic c Tanks (a) capacities-150� of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10t from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes Z(j (a) s ope greater than 0.08 Reg 10.4 (b) mup U.�✓� l�5 ����Gw,Q-'�O' BOARD OF HEALTH No.Andover, Mass . G�L� SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT #SoOTH-ISWWj KV APPROVED DATE DISAPPROVED DATE Provided: Reasons: . Np Title V FAIL 0g Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any vet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sesage disposal system or disclaimer-Planning Board files (J) knosn sources of Water supply within 2001 of sewage disposal d system or disclaimer (k) location of any proposed shell to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-15076 of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) lot from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) —slope greater than 0.08 Reg 10.4 b) sump M d 30ARD GF HEALTH , No.Andaver, .^'lass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # APPROVED DATE —25 DISAPPROVED DATE Provided: Reasons s Title V FAIL CSC Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dissensions lot #,abutters b location aad log deep observation holes-distance to ties c location and results percolation testa-distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer-Planning Board files (J) known sources of water supply within 2001 "of sewage disposal system or disclaimer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other' elevations (r) mmd=m ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities-15U of flow, water table, tees, depth of tees, access, punning (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 7 Distribution Boxes (a) Iso—pe greater 0.08 Reg 10.4 b) mup r Commonwealth of Massachusetts Cito own of NORTH ANDOVER, MASSACHUSETTS _ Sy spm Pumping Record DEP has provided this form for use by local Boards of Health. a �� �� Rec rd must be submitted to the local Board of Health or other approving au hoirity. A. Facility Information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: HEALTH DEPARTMENT forms on the computer,use only the tab key Address ' /� to move your /li �X /�-t�+r cursor-do not �D y� use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town StateZip Code �� Telephone Number B. Pumping Record 1. Date of PumpingD t 2. Quantity Pumped: Gau/S� a 3. Type of system: ❑ Cesspool(s) Ej-*!§'eptic Tank ❑ Tight Tank ❑ Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes D<lo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sys m Pumped By: a e Vehicle License Number Company 7. Location where contents were disposed: S' natu Dat http://www.` ass. /de ater/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealthof assac usetts RECEIVED City/Town of System Pumping Recor � DEC 0 2008 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms rr aye use-d-,15 e information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 5S Clues ri Qn V only the tab key Address ^ _ to move your cursor-do not Nor'�� Ar )U oNe( MQ O) T O �f_S use the return City/Town State Zip Code key. 2. System Owner: Sia wn S Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping q- 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) v❑"'Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ["No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C.W 6. System Pumped By: -AM-) GaaY4 9 Name Vehicle License Number WiVA et anyiconrnen)iCA Company Ipswich Water 7. Location where contents were disposed: Treatment Plant 1H%JVV1L'l 11 IVIA 01938 � (/ SiNature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 CIV � Commonwealth of Massachusetts City/Town of APR -7 N 11 System Pumping Record NORTH ANDOVER tOINOFNORTH AND20VER Form 4 HEALTH DEPARTMENT h DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the , computer,use � ZP� h— —. -- --- — — ------- -...—. only the tab key Address to move your ---------- ----_--- --...---------- cursor-do not y - - ----- State use the return Cily/Town Zip Code key. 2. System Owner: Name Address(if different from location) --- --- - ------- City/Town State Zip Code 1166 Telephone Number B. Pumping Record 1. Date of Pumping - 2. Quantity Pumped: --- ---- Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: -- - - ---- i-� '----- -- Signature of Hauler- -------- Da--te Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1